TRANS AND GENDER DIVERSE VOICE ......The competency framework may form part of the formal appraisal...

Trans and Gender Diverse Voice & Communication Therapy Competency Framework

DRAFT FOR MEMBER CONSULTATION: JANUARY 2017

TRANS AND GENDER DIVERSE

VOICE & COMMUNICATION THERAPY

Competency Framework



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First published in xxxx by the Royal College of Speech and Language Therapists

2 White Hart Yard, London SE1 1NX 020 7378 1200 www.rcslt.org

Copyright © Royal College of Speech and Language Therapists xxxx Date for review: xxxx

Procedure for reviewing the document: A group of experts working across sectors

will be identified and asked to review the document to determine whether an update is

required. Members can submit their feedback on the document at any time by

emailing: [email protected]

Scope of the document

This document is a training and competency framework for speech and language

therapists (SLTs) working with trans and gender diverse people. The framework defines competency in relation to trans and gender diverse voice and communication assessment and therapy, and not in relation to clinical voice disorders assessments and

therapy. It is a UK-wide document.

The document aims to support the commissioning of services to deliver a more equitable service to trans clients nationally.

Acknowledgements

If applicable

http://www.rcslt.org/

mailto:[email protected]



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Working Group

Name Job title Employer

Matthew Mills

Lead Specialist Speech and Language

Therapist at the Gender Identity

Clinic, London

West London Mental

Health NHS Trust

Remaining working group members to be confirmed following open application process.

Tbc

Tbc

Tbc

Tbc



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Contents

To be added when content has been finalised



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1 Introduction and context

1.1 The role of speech and language therapy

Gender identity is “an individual’s personal sense, and subjective experience, of their

own gender” (NHS England, 2016). An individual’s voice is a central part of their identity; it is how they communicate with their family, friends, work colleagues, and wider society.

As part of a multi-disciplinary team (MDT), SLTs have a key role to play in ensuring the

best possible outcomes for trans and gender diverse people. SLTs, with the appropriate level of competence, can support voice modification, facilitating gender expression through vocal and communication style changes. Voice and Communication Therapy

enables trans and gender diverse people to align their vocal and communicative expression with their identity in ways that feel congruent and authentic with their

sense of self. This can help to reduce distress related to gender dysphoria, which can cause a lack of

confidence and participation in communication. It can also help tackle transphobia and misgendering and transphobia (for example, people being vocally misgendered on the

telephone, or ridiculed in social or workplace contexts because of their voice).

1.2 Key objectives of this document

To support individual SLTs working with trans and gender diverse people

to develop the necessary competencies to operate safely and effectively in this specialist field, and make the case for access to appropriate

supervision and support. To provide a tool which can be used by supervisors and managers to

identify areas of professional development.

To support the development of the speech and language therapy workforce, to enable the delivery of a more equitable service for trans

clients across the UK. To guide the commissioning of speech and language therapy services for

trans and gender diverse clients in delivery of Voice and Communication

Therapy

1.3 Context of the speech and language therapy workforce

Access to speech and language therapy for trans and gender diverse clients is patchy geographically, with very few clinically experienced SLTs in this field nationally.

The geographic variation in England in partly due to location of Specialised Clinical

Services for the care of Gender Dysphoria (SCSGDs). There are currently seven gender identity clinics/centres in England – in London, Nottingham, Leeds, Sheffield, Newcastle, Exeter and Northampton. However, even some of the GICs do not currently

have a dedicated SLT as an integral member of the MDT.



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Some local speech and language therapy services do have SLTs who have developed

considerable experience working with trans clients over several years. However, these senior SLTs often do not have regular access or input to an MDT.

Furthermore, some speech and language therapy services in District General Hospitals, outpatient or community services, may not have a clinically experienced SLT at all.

At the time of writing, the current Interim Protocol and Service Specification (NHS

England, 2013) is being reviewed by the Clinical Reference Group for NHS England Specialised Gender Identity Services who are tasked to deliver new specifications and innovations in models of care in order to address the concerns identified by the

Government Select Committee and Transgender Network.

1.4 Key audiences

SLTs working in voice services who may receive referrals for trans or gender

diverse clients SLTs working in specialist gender identity services

Managers or supervisors of SLTs providing voice and communication therapy to trans clients

Commissioners of services for trans and gender diverse clients

1.5 Scope of practice

As with all professional practice, SLTs should ensure that they comply with the HCPC standards of proficiency and operate only within their scope of practice.

“Your scope of practice is the area or areas of your profession in which you have the

knowledge, skills and experience to practice lawfully, safely and effectively, in a way that meets our standards and does not pose any danger to the public or to yourself” (HCPC, 2013, p.4).



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2 Using the framework

2.1 Purpose

The competency framework brings together knowledge, skills and practical competencies. It is intended that the competency framework be used by practising

SLTs, with evidence being provided and practice supervised or independently signed off by an appropriately skilled supervisor.

2.2 Who is the competency framework for?

This competency framework has been commissioned and written by the RCSLT. It is for the use of the speech and language therapy profession only.

2.3 How should the competency framework be used?

The framework is hierarchical: each level is built upon the foundations of the one below it. It is possible that a clinician may be developing competencies across two different levels at the same time. This would be perfectly acceptable; however, the SLT must

have signed off all sections of each level before the SLT is deemed competent at that level, even if they are working on some aspects of a level above.

If the assessment and management of trans voice and communication is part of the job role this should be clearly stated within the job description. As part of the induction

process within the organisation, the line manager/supervisor should ask the new employee for a copy of his or her competency framework.

The competency framework may form part of the formal appraisal process with the employing organisation.

2.3.1 Obtaining, recording and maintaining competencies

Competencies can be worked towards through a number of ways, including: reading, reflective practice in supervision, educational videos, written logs, observation and

shadow working, appraisal, journal club, attendance and courses, membership of a CEN, MDT working, supervision and line management.

It is acknowledged that some of the knowledge at the higher levels may be acquired

through reading or organisation-based tutorials, or may require access to specific courses.

As with all aspects of the SLT role, the individual SLT bears responsibility for his or her own competence. It may be appropriate therefore for SLTs who have not worked in this

area for some time to update their competence by reviewing some of the competencies previously achieved.



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2.4 Guidance for supervisors

As with all professional practice, supervisors should ensure that they comply with HCPC standards of proficiency and practise and supervise only within their scope of practice.

Supervisor requirements

1) Supervisors are required to have significant knowledge, skills and experience in the field of trans voice and communication therapy. It would be preferable

(ultimately) for a supervisor to be signed off to at least Level C; however, it is recognised that some supervisors may have achieved their competence before this competency framework is implemented.

2) Supervisors should also be able to demonstrate ongoing practice and CPD in the area of trans voice and communication therapy.

3) Supervisors should be familiar with the knowledge, skills and competence required and be able to direct SLTs to relevant reading.

4) Supervisors should be able to teach aspects of the knowledge and skills

required or identify courses that would provide this.

5) Supervisors will be required to sign the competency framework

The supervisor role and the signing-off of the competency framework are very important. It is emphasised that supervisors are signing knowledge, skills and/or

competency in the context observed, but that ongoing support, supervision and CPD will be necessary.

In signing the competency framework the supervisor is signing that she/he is confident that the supervisee has the relevant knowledge, skills and/or practical competence at

that point in time. It should be noted that the supervisor may like to keep evidence/documentation of why she/he was confident in this, in case there are any

issues regarding the practice of the supervisee in the future, for example, within an HCPC investigation.

It is recommended that supervisors:

keep copies of the relevant competency framework documentation and notes of

all aspects of the competency framework that they sign for others, so that they have a clear record

have undertaken training in the supervision of others. be in receipt of formal, individual and peer supervision within this clinical area.

For more information on supervision, please see the RCSLT website: https://www.rcslt.org/cq_live/resources_a_z/supervision/supervision

https://www.rcslt.org/cq_live/resources_a_z/supervision/supervision



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2.5 Guidance for employers

The competency framework is designed for use in the practical acquisition of competence in the area of trans voice and communication therapy. The employer is

responsible for ensuring that the roles and responsibilities associated with trans and gender diverse clients are clearly detailed in the SLT’s job description.

Employers have a responsibility to ensure that the supervisor has adequate skills to provide supervision and teaching in this area and that this is clearly detailed in their

job description. Employers should ensure that adequate time is given for supervision. If there is no suitable supervisor within the employing organisation, employers may

arrange for a supervisor from another organisation, but should ensure that this fits within a professional and clinical governance framework. Again, employers have a

responsibility to ensure that the supervisor has adequate skills to provide supervision and teaching in this area and that this is clearly detailed in their job description.

As with all clinical areas it is advised that employers ensure there is appropriate supervision in place for the supervisor.



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RCSLT Trans and Gender Diverse Voice & Communication Therapy Competency Framework - Level A

An SLT at Level A is likely to be newly working in a voice service, with little or no experience of working directly with trans clients.

Name ………………………………………………………………………………………….

Clinical caseload/client group ……………………………………………………….

Competency Suggested learning

task Evidence

Date

completed

Supervisor

sign off

A1 Understanding of gender identity Suggested learning task

A1.1 Able to use terminology appropriately

e.g. transgender, gender dysphoria trans man, trans woman, non-binary

person, and apply pronouns accurately

A2 Trans voice & communication

therapy

A2.1 Knowledge

A2.1.1 Understand the role of speech and

language therapy for trans clients

A2.1.2 Knowledge of gender differences in

voice and communication without assumption or stereotyping

A2.2 Practical skills

A2.2.1 Able to use objective and perceptual

measures of pitch, range, intonation, and perceptually identify resonance

characteristics



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RCSLT Trans and Gender Diverse Voice & Communication Therapy Competency Framework - Level B

An SLT working at Level B will be experienced working with clinical voice disorders, and have some limited experience of working with trans clients – perhaps 1 – 5 new clients per year.

Name ………………………………………………………………………………………….


Competency Suggested learning task

Evidence

Date completed

Supervisor sign off

B1 Understanding of gender identity Suggested learning task

B1.1 Understand gender as a continuum

B1.2 Knowledge of current ICD and DSM

classifications of gender dysphoria

B1.3 Knowledge of social role change and transition process for trans people

B1.4 Awareness of gender identity clinics and the roles of various gender specialists

within the MDT

B1.5 Understand psychological models e.g. psychodynamic, humanistic, cognitive

B1.6 Knowledge of hormone interventions for trans men and trans women and impact

on voice and appearance



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Evidence

Date completed

Supervisor sign off

B1.7 Awareness of the fundamentals regarding gender surgeries

B1.8 Awareness of the fundamentals regarding pitch surgeries

B1.9 Awareness of current WPATH Standards of Care (WPATH, 2012) and the Gender Recognition Act 2004

B1.10 Awareness of risk factors of gender dysphoria e.g. distress and suicide

ideation, and the need for GP liaison.

B2 Trans voice & communication

therapy

B2.1 Knowledge

B2.1.1 Knowledge of service referral criteria

B2.1.2 Knowledge of vocal hygiene and care,

and hyperfunctional risk factors in voice modification

B2.1.3 Understand how other diagnoses (e.g. Autism Spectrum Disorder, learning

disability) may require adaptations to voice and communication therapy

B2.1.4 Awareness of qualitative and quantitative measures for all vocal parameters



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Evidence

Date completed

Supervisor sign off

B2.2 Practical skills

B2.2.1 Able to deliver interventions in pitch,

resonance, intonation, range and voice quality for trans women

B2.2.2 Able to use audio and visual feedback systems to support client

B2.2.3 Able to recognise, produce and model appropriate pitch parameters for trans women with the use of apps and devices

B2.2.4 Able to model and contrast head and chest resonance

B2.2.5 Able to model laryngeal and articulatory postures

B2.2.6 Able to model and contrast dynamic communication and non-verbal gender

markers (without stereotyping)

B2.2.7 Counselling skills and knowledge of key

psychological approaches e.g. cognitive behavioural therapy (CBT)

B2.2.8 Skills in personal experiential voice work beyond rehabilitative exercises



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RCSLT Trans and Gender Diverse Voice & Communication Therapy Competency Framework - Level C

An SLT who is signed off at Level C can demonstrate competent performance in the assessment and management of trans and gender diverse clients.

The SLT at Level C will supervise, support and train others in voice and communication therapy for trans clients. Ideally, the Level C SLT will receive support and supervision from an SLT working at Level D.

SLTs may work at Level C for many years without fully moving to Level D. Examples of practitioners who may be working at Level C:

o A practitioner who is an experienced SLT working with clinical voice disorders, with substantial experience of working

with trans clients – perhaps 6 - 19 new clients per year.

Name ………………………………………………………………………………………….



Evidence

Date completed

Supervisor sign off

C1 Understanding of gender identity Suggested learning task

C1.1 Awareness of current debate on

definitions and terminology

C1.2 Understanding of gender spectrum and

gender diversity

C1.3 Understanding of complexity of social

role change and transition process for trans people

C1.4 Knowledge of assessment process for gender dysphoria and psychological / psychotherapeutic interventions available



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Evidence

Date completed

Supervisor sign off

C1.5 Knowledge of specific pathways and timings of gender surgeries for trans men, trans women and gender diverse

clients

C1.6 Knowledge of thyroid cartilage reduction

procedures and outcomes

C1.7 Knowledge of UK’s Good Practice

Guidelines (RC Psych, 2014) and relevant current legislature and protocols

C2 Trans voice & communication therapy

C2.1 Knowledge

C2.1.1 Understanding of subtleties of gender

expression in voice and communication

C2.1.2 Understanding of SLT’s role in facilitating

vocal congruence with gender role at a holistic level including psychological

ownership of authentic voice and its generalisation in individual and group sessions (if practical)

C2.1.3 Awareness of client reported lived experience as outcome measure



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Evidence

Date completed

Supervisor sign off

C2.1.4 Familiar with psychological approaches to support clients’ alleviation of gender dysphoria in gender expression related

to voice modification intervention

C2.1.5 Knowledge of the trajectory of voice and

communication therapy within the transition process for trans people

C2.2 Practical skills

C2.2.1 Able to deliver interventions in pitch,

resonance, intonation, range and voice quality for trans men

C2.2.2 Able to recognise, produce and model appropriate pitch parameters for trans

men and gender diverse clients with the use of apps and devices

C2.2.3 Able to model and contrast dynamic communication and non-verbal gender markers without stereotyping

C2.2.4 Able to give sensitive feedback on posture and non-verbal communication

markers, where appropriate



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Evidence

Date completed

Supervisor sign off

C2.2.5 Skills in personal experiential voice work gained from clinical voice and voice development pedagogy to support

modelling and understanding of the client’s change process.

C3 Supervision and education

C3.1 Provides support and supervision to

other colleagues working with trans clients.



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RCSLT Trans and Gender Diverse Voice and Communication Therapy Competency Framework - Level D

SLTs working at this level are highly-specialised, autonomous practitioners and are likely to be predominantly working with trans clients.

They will be supporting and supervising staff who work at Level C to develop their competencies. They will access supervision from peers, who may be outside of their department or profession e.g. a non-SLT gender

specialist. The Level D practitioner will take a lead in keeping up-to-date with research and evidence-based practice and strategic

developments, and disseminating this to others.

They will seek out and respond to opportunities to further knowledge of this specialist field within the wider profession, working on or contributing to working parties, research and advisory boards.

Level C practitioners developing Level D competence

It is probable that many SLTs operating at Level C will also demonstrate Level D competencies in some areas without working at

Level C overall. Where this is the case, SLTs are encouraged to populate the relevant sections of this document.

Name ………………………………………………………………………………………….


Competency Competency assurance Evidence

Further ongoing action

plan for developing own clinical skill and

competence following peer supervision

D1 Understanding of gender identity e.g.

D1.1 Understanding of gender politics, gender

diversity, gender fluidity and current discourse in LGBTQ issues



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Further ongoing action plan for developing own clinical skill and


D1.2 Understanding of risk factors to de-transition

D1.3 Knowledge of Gender Recognition Certificate process

D1.4 Understanding of current issues in commissioning and care pathways and

service specification

D1.5 Awareness of current commissioning and

funding issues, and care pathways, for pitch surgeries and thyroid cartilage reduction procedures.

D2 Trans voice & communication therapy

D2.1 Knowledge

D2.1.1 Understanding of gender expression in voice and communication across the gender spectrum

D2.1.2 Understanding of protocols for treatment of risk factors of gender dysphoria e.g.

distress and suicide ideation



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D2.2 Practical skills

D2.2.1 Able to deliver interventions in pitch, resonance, intonation, range and voice

quality for gender diverse clients

D2.2.2 Able to input into complex case discussions as part of the MDT

D2.2.3 Able to carry out assessments for phono surgery suitability as part of MDT

treatment recommendations

D2.2.4 Experience of adapting voice and communication therapy for clients with

physical and/or mental health diagnoses

D2.2.5 Experience with trans men and gender diverse clients’ individual voice care needs in relation to hormone therapy

D2.2.6 Able to demonstrate chest, pharyngeal, oral, facial, and head resonances, and how clients can acquire these, including work with trans men and gender diverse

people



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D3 Supervision and education

D3.1 Provides supervision to local SLTs

working at Levels B and C, and others at Level D

D3.2 Regular liaison with SLTs working with trans clients at all levels

D3.3 Provides support to other SLTs with regard to developing experiential voice

skills

D3.4 Contributes to education and research in

the field

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3 References

Health and Care Professions Council (HCPC) (2013). Standard of proficiency –

Speech and language therapists. [Online]. Available at: http://www.hcpc-

uk.org/publications/standards/index.asp?id=52

NHS England (2013). Interim Gender Dysphoria Protocol and Guideline 2013/14.

[Online]. Available at: https://www.england.nhs.uk/wp-

content/uploads/2013/10/int-gend-proto.pdf

NHS England (2016). C05. Gender Identity Services (Adults) Available at:

https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-c/c05/

Royal College of Psychiatrists (2013). Good practice guidelines for the

assessment and treatment of adults with gender dysphoria. [Online]. Available

at: http://www.rcpsych.ac.uk/files/pdfversion/CR181_Nov15.pdf

World Professional Association for Transgender Health (WPATH) (2012).

Standards of Care for the Health of Transsexual, Transgender, and Gender

Nonconforming People (7th version). [Online]. Available at:

http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk

_association_webpage=3926

http://www.hcpc-uk.org/publications/standards/index.asp?id=52

http://www.hcpc-uk.org/publications/standards/index.asp?id=52

https://www.england.nhs.uk/wp-content/uploads/2013/10/int-gend-proto.pdf

https://www.england.nhs.uk/wp-content/uploads/2013/10/int-gend-proto.pdf

https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-c/c05/

http://www.rcpsych.ac.uk/files/pdfversion/CR181_Nov15.pdf

http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_association_webpage=3926

http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_association_webpage=3926

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Appendix: Methodology

Gender dysphoria workshop

In June 2014 the RCSLT hosted a workshop for SLTs and others with a role in voice and communication therapy for clients with gender dysphoria. The

workshop included a discussion about the competencies required, and the need for a competency framework was identified. As a result of the workshop, a first

draft competency framework was created and shared.

National Transgender Voice and Communication Therapy Clinical Excellence Network

In October 2015 a new clinical excellence network (CEN) was established for

SLTs working in this field. Ahead of the inaugural meeting of the CEN, a revised version of the framework was shared, and on the day a workshop was held to gather initial feedback. As a result of the feedback, and suggestions from the

RCSLT on the format of the framework, a subsequent draft was developed and submitted to the RCSLT for wider consultation.

Consultation with the profession

To be completed following the consultation

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